A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?
Wear an N95 mask when in the client's room.
Wear a gown when caring for the client.
Wear a simple face mask when caring for the client.
Place the client in a negative air pressure room.
The Correct Answer is A
Choice A reason: Wearing an N95 mask when in the client's room is an appropriate instruction, as it can protect the AP from inhaling airborne droplets that contain pertussis bacteria, which can cause a highly contagious respiratory infection.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason: Wearing a simple face mask when caring for the client is not sufficient, as it does not filter out small particles that can carry pertussis bacteria and enter the respiratory tract.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.
Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.
Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.
Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.
Correct Answer is A
Explanation
Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.
Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.
Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.
Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.
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